John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

It’s been a while since we’ve done a Twitter roundup, so it was time to do one again. This time we highlight 3 recent tweets that will make you go hmmmmm. Lots of great insights from amazing people.

More and more people are open to sharing their records. However, there’s still a lot of education needed for people that are afraid that sharing their records could harm them. While there is that risk, it’s important to remember that not sharing your records could harm you too.

T1: Vendors have a responsibility to make a functional, easy-to-use #EMR. Leadership has a responsibility to provide education and resources to empower #clinicians. Clinicians have a responsibility to be proactive in their EMR experience (e.g. customization). #hcldr#usability

Is this the right balance or resonsibility? Should vendors, leaders, and clinicians all be responsible? Is the reason EMRs aren’t usable is that it takes all 3 of these groups working together to make it usable?

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

In theory, you want everyone who accesses a patient’s health data to leave a clear footprint. As a result, it’s standard to assign every clinician using EMR data to be assigned a unique user ID and password. Most healthcare organizations assume that this is a robust way to document who is using the system and what they do when they’re online.

Unfortunately, this may not be the case, which in turn means that providers may know far less about health data users than they think. In fact, this approach may actually undermine efforts to track health data access, according to a new study appearing in the journal Healthcare Informatics Research.

The researchers behind the study created a Google Forms-based survey asking medical and para-medical personnel whether they’d ever obtained another medical staff member’s password, and if so, how many times and what their reasons were.

They gathered a total of 299 responses to their questions. Of that total, 220 respondents (just under 74%) had “borrowed” another staff member’s password. Only 57% answered the question of how many times this had happened, but among those who did respond the average rate was 4.75 episodes. All of the residents taking part had obtained another medical staff member’s password, compared with 57.5 percent of nurses.

The reasons medical staffers gave for sharing passwords included that “I was not given a user account despite having to use the system to fulfill my duties.” This response was particularly prevalent among students. Researchers got similar results when naming the reason “the permissions granted to me did not allow me to a fulfill my duties.”

Given their working conditions, it may be hard for medical staff members to avoid bending the rules. For example, the authors suggest that doctors will at times feel compelled to share password information, as their duties are wide-ranging and may involve performing unplanned services. Also, during on-call hours, interns and residents may need to perform activities that require them to use others’ EMR account information.

The bottom line, researchers said, is that the existing approach to health data security are deeply flawed. The current password-based approach used by most healthcare organizations is “doomed” by how often clinicians share passwords, they argue.

In other words, putting these particular safeguards in effect may actually have the paradoxical effect. Though organizations might be tempted to strengthen the authentication process, doing so can actually worsen the situation by encouraging system workarounds.

To address this problem over the long-term, widely-accepted standards for information security may need to be rethought, they wrote. Specifically, while the ISO standard bases infosec on the principles of confidentiality, integrity and availability, organizations must add usability to the list. Otherwise, it will be difficult to get an-users to cooperate voluntarily, the article concludes.

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

While the current crop of EHRs have (arguably) served a useful purpose, I think we’d all agree that there’s a ton of room for improvement. The question is, what will it take to move EHRs forward?

Certainly, we face some significant obstacles to progress.

There are environmental factors in play, such as reimbursement issues.

There’s the question of what providers will do with existing EHR infrastructure, which has cost them tens or even hundreds of millions of dollars if next-gen EHRs call for a new technical approach.

Then, of course, there’s the challenge of making the darn things usable by real, human clinicians. So far, we simply haven’t gotten anything that solves that issue yet.

That doesn’t mean people aren’t considering the issue, however. One health IT leader that’s stepped up to the plate is Dr. John Halamka, chief information officer of the Beth Israel Deaconess Medical Center and CIO and dean for technology at Harvard Medical School.

In his Life As Healthcare CIO, Halamka lays out the changes he sees as driving the shift to EHR 2.0. Here are some of his main points:

Regulators are shifting their focus from prescribing certain types of EHR functionality to looking at results technology achieves. This supports the healthcare industry’s movement from a data recording focus to an outcomes focus.

With doctors being pulled in too many directions, it will take teams to maintain patient health, this calls for a new generation of communication and groupware tools. These tools should include workflow integration, rules-based escalation messages, and routing based on time of day, location, schedules, urgency, and licensure.

With value-based purchasing gradually becoming the norm, EHRs need new capabilities. These should include the ability to document care plans and variation from those plans, along with outcomes reported from patient-generated healthcare data. Eventually, this will mean the dawn of the Care Management Medical Record, which enrolls patients and protocols based on their condition then ensures that patients get recommended services.

EHRs must be more usable. To accomplish this, it’s helpful to think of EHRs as platforms upon which entrepreneurs can create add-on functionality, along the lines of apps that rest on top of mobile operating systems.

Next-gen EHRs need to become more consumer-driven, making patients an equal member of the care team. Although existing EHR models do have patient portals, they aren’t robust enough to connect patients fully with their care, and they don’t include tools helping patients navigate their care system.

As far as I can tell, Dr. Halamka has covered the majority of issues we need to address in transitioning to new EHR models. I was also interested to learn that regulatory bodies have begun to “get it” about the limitations of demanding certain functions be included in an EHR system.

I’m still left with one question, however. How does interoperability fit into this picture? Can we even get to the next generation of EHRs without answering the question of how they share data between one another? To me, it’s clear that the answer is no, we can’t leave this issue aside.

Other than that, though, I found Dr. Halamka’s analysis to be fairly comforting. Nothing he’s described is out of reach, unless, of course, vendors won’t cooperate. I think that as providers reach the conclusions he has, they’ll demand the kind of functionality he’s outlined, and vendors will have no choice but to pony up. In other words, there might actually be light at the end of the EHR tunnel.

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

I don’t know about you, but I was totes surprised to hear about another study pointing out that doctors have good reasons to hate their EHR. OK, not really surprised – just a bit sadder on their account – but I admit I’m awed that any single software system can be (often deservedly) hated this much and in this many ways.

This time around, the parties calling out EHR flaws were the American Medical Association and the University of Wisconsin, which just published a paper in the Annals of Family Medicine looking at how primary care physicians use their EHR.

To conduct their study, researchers focused on how 142 family physicians in southeastern Wisconsin used their Epic system. The team dug into Epic event logging records covering a three-year period, sorting out whether the activities in question involved direct patient care or administrative functions.

When they analyzed the data, the researchers found that clinicians spent 5.9 hours of an 11.4-hour workday interacting with the EHR. Clerical and administrative tasks such as documentation, order entry, billing and coding and system security accounted about 44% of EHR time and inbox management roughly another 24% percent.

As the U of W article authors see it, this analysis can help practices make better use of clinicians’ time. “EHR event logs can identify areas of EHR-related work that could be delegated,” they conclude, “thus reducing workload, improving professional satisfaction, and decreasing burnout.”

The AMA, for its part, was not as detached. In a related press release, the trade group argued that the long hours clinicians spend interacting with EHRs are due to poor system design. Honestly, I think it’s a bit of a stretch to connect the study results directly to this conclusion, but of course, the group isn’t wrong about the low levels of usability most EHRs foist on doctors.

To address EHR design flaws, the AMA says, there are eight priorities vendors should consider, including that the systems should:

I’m not sure all of these points are as helpful as they could be. For example, there are approximately a zillion ways in which an EHR could enhance the ability to provide high-quality care, so without details, it’s a bit of a wash. I’d say the same thing about the digital/mobile patient engagement goal.

On the other hand, I like the idea of reducing cognitive workload (which, in cognitive psychology, refers to the total amount of mental effort being used in working memory). There’s certainly evidence, both within and outside medicine, which underscores the problems that can occur if professionals have too much to process. I’m confident vendors can afford design experts who can address this issue directly.

Ultimately, though, it’s not important that the AMA churns out a perfect list of usability testing criteria. In fact, they shouldn’t have to be telling vendors what they need at this point. It’s a shame EHR vendors still haven’t gotten the usability job done.

Colin Hung is the co-founder of the #hcldr (healthcare leadership) tweetchat one of the most popular and active healthcare social media communities on Twitter. Colin speaks, tweets and blogs regularly about healthcare, technology, marketing and leadership. He is currently an independent marketing consultant working with leading healthIT companies. Colin is a member of #TheWalkingGallery. His Twitter handle is: @Colin_Hung.

Last week I had a rare healthcare experience – something that I had only read about in blogs and on Twitter – a physician showed me what he was entering into him EHR while I sat beside him in the exam room! I’m not ashamed to admit that my first thought was “I can’t believe this is really happening”.

The doctor must have noticed how I quickly moved my seat closer to the large monitors because he chuckled and asked me: “How long have you been in healthcare?”. After sharing a laugh he went on to say “It’s rare that patients take a keen interest in what I’m keying into the system. It’s usually other healthcare people that want to see what’s going on. Are you a nurse or a physician?”

When I told him I was in Healthcare IT field he smiled and said “Ah that would have been my third guess.”

For the next 20 min he would type a line of notes, point to the screen and then share his reasoning with me. I asked him questions on clinical terms that I did not understand, at which point he would bring up a resource that had a definition. If he didn’t have a ready resource, he explained it as best he could and then encouraged me to look it up on a trusted site like Mayo Clinic’s.

Near the end of the appointment, the doctor asked me if I was involved with EHRs. When I asked him why, he said the most intriguing thing – “because it’s clear to me that the people who design EHRs (a) have never actually seen a patient in an exam room – it’s ridiculous how awful the screens are and (b) never thought that one day doctors would sit beside patients to let them see what they are entering.”

The latter statement has been churning through my mind ever since.

There is little doubt that the majority of EHRs are less-than-well-designed. Physicians everywhere complain about the amount of clicking required to navigate their EHRs and the number of fields they have to enter. The prevailing opinion is to improve EHRs by getting closer to physicians and actually studying how they really conduct a patient visit. This will certainly yield positive results.

But what if we designed an EHR that was meant to be displayed on a big screen? One that had screens that the patients would see as the doctor entered his or her notes? I believe that designing for this type of usage would result in a more significant improvement in usability and have a more positive impact on patient experience than building EHRs based on better observation of physician workflow.

Consider the phenomenon of open kitchens in the restaurant industry. For diners, being able to watch the kitchen staff prepare meals helps to pass the time while waiting for your order. It also allows the diner to see how talented the chefs are – because they can see them working. For staff, an open kitchen often means that the restaurant has put a lot of thought into optimizing food prep workflow. After all, no one would choose a layout that had staff constantly bumping into each other in full view of diners.

If a company designed an EHR that could be shared with patients, they would not only improve the interface for physicians, but they would also provide a means for that physician to improve the overall patient experience.

I hope that more physicians adopt the practice of sharing their EHR screens with patients during a visit. Doing so will immediately improve patient experience and will push vendors to improve their solutions at a far greater pace.

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Here’s an argument that’s likely to upset some, but resonate with others. After kicking the idea around in my head, I’ve concluded that given broad cultural trends, that the healthcare industry as a whole has outgrown the use of paper records once and for all. I know that this notion is implicit in what health IT leaders do, but I wanted to state this directly nonetheless.

Let me start out by noting that I’m not coming down on the minority of practices (and the even smaller percentage of hospitals) which still run on old-fashioned paper charts. No solution is right for absolutely everyone, and particularly in the case of small, rural medical practices, paper charts may be just the ticket.

Also, there are obviously countless reasons why some physicians dislike or even hate current EMRs. I don’t have space to go into them here, but far too many, they’re hard to use, expensive, time-consuming monsters. I’m certainly not trying to suggest that doctors that have managed to cling to paper are just being contrary.

Still, for all but the most isolated and small providers, over the longer term there’s no viable argument left for shuffling paper around. Of course, the healthcare industry won’t realize most of the benefits of EMRs and digital health until they’re physician-friendly, and progress in that direction has been extremely slow, but if we can create platforms that physicians like, there will be no going back. In fact, for most their isn’t any going back even if they don’t become more physician firendly. If we’re going to address population-wide health concerns, coordinate care across communities and share health information effectively, going full-on digital is the only solution, for reasons that include the following:

Millennial and Gen Y patients won’t settle for less. These consumers are growing up in a world which has gone almost completely digital, and telling them that, for example they have to get in line to get copies of a paper record would not go down well with them.

Healthcare organizations will never be able to scale up services effectively, or engage with patients sufficiently, without using EMRs and digital health tools. If you doubt this, consider the financial services industry, which was sharing information with consumers decades before providers began to do so. If you can’t imagine a non-digital relationship with your bank at this point, or picture how banks could do their jobs without web-based information sharing, you’ve made my point for me.

Without digital healthcare, it may be impossible for hospitals, health systems, medical practices and other healthcare stakeholders to manage population health needs. Yes, public health organizations have conducted research on community health trends using paper charts, and done some effective interventions, but nothing on the scale of what providers hope (and need) to achieve. Paper records simply don’t support community-based behavioral change nearly as well.

Even small healthcare operations – like a two-doctor practice – will ultimately need to go digital to meet quality demands effectively. Though some have tried valiantly, largely by auditing paper charts, it’s unlikely that they’d ever build patient engagement, track trends and see that predictable needs are met (like diabetic eye exams) as effectively without EMRs and digital health data.

Of course, as noted above, the countervailing argument to all of this is the first few generations of EMRs have done more to burden clinicians than help them achieve their goals, sometimes by a very large margin. That seems to be largely because most have been designed — and sadly, continue to be designed — more to support billing processes than improve care. But if EMRs are redesigned to support patient care first and foremost, things will change drastically. Someday our grandchildren, carrying their lifetime medical history in a chip on their fingernail, will wonder how providers ever managed during our barbaric age.

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I came across this tweet from Howard Green, MD that really made me stop to think.

@nickisnpdx We tell our kids to put down their devices and interact. We tell our doctors pick up EMR devices and stop interacting #EMR

I like the juxtaposition of his comment because it makes you stop and think about the decisions we’re making. Although, I think that Dr. Green takes it too far since no one ever asked doctors to stop interacting. In fact, the chorus I’ve heard is that doctors need to interact more with patients. That said, I get his point that the EMR can get in between the patient and doctor if you let it. And many have let it get in the way.

We can certainly talk about how EHR software could be more usable. We can talk about how the onerous regulations and things like meaningful use and MACRA have made documenting in an EHR a clickfest that provides little to no value to patients. We can talk about how EHR software isn’t connected to other EHR software and we’re living in this world of healthcare data silos. All of these are a pain and a problem for doctors and we should do better. What is unfair to say is that EHRs tell doctors to stop interacting.

It’s always amazing to me how the EHR gets all sorts of undeserved blame. I’ve seen plenty of doctors who use an EHR and still spend plenty of time interacting with their patients. In fact, people like Dr. James Legan have integrated their EHR use into their patient interaction and made their patient interaction better. Yes, the EHR can be a distraction, but it doesn’t have to be. The same way devices can ruin my children, but they don’t have to ruin them. It’s how you choose to use it.

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com.For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manager doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst, a role he recently repeated for a Council member.

My friend Joe is a retired astrophysicist turned web geek. Joe’s had his health problems, but he’s still an avid bicycle rider as well as one of the most well read persons I’ve ever known. He doesn’t miss much, and always has his own – often original – take on politics, the economy, the net and a lot else.

There is one topic where his take echoes many others. He never fails to send me posts about how EHRs interfere in the doctor – patient relationship. He just loathes it when his doc spends time keying away rather than making eye contact.

Joe knows I get pretty wound up on EHR usability and interop problems, but that just makes me an even better target for his disgruntlement. He, of course, has a point as do so many others who’ve lamented that what was once a two way conversation has become a three way with the patient the loser.

The point, I think, only goes so far. What’s going on in these encounters is more than the introduction of an attention sucking PC. It’s simply wrong to assume that medical encounters were all done the same warm and fuzzy way until EHRs came along. To understand EHRs’ effect from a patient’s perspective, I think we need to ask ourselves several questions about our EHR involved medical appointments.

Whose Appointment Is It? Are you there alone, with an elderly parent, your spouse or your child, etc.?

Appointment’s Purpose. Why are you there? Is it for a physical, is it due to bad cold, a routine follow up or is it for a perplexing question? Is it with a specialist, pre or post op?

Your Relationship. How long and how well have you know this doctor? How many doctors have you had in the past few years?

How Long Has It Been? When was the last time you saw your doctor, days, weeks, years? How much catching up is there to do?

Doc’s Actions. What’s your doc doing on the EHR, looking for labs, going over your meds, writing notes, writing prescriptions, ordering tests, checking drug interactions? How many of these would have been impossible or difficult on paper?

Money. How much time does your doc take trying to save you money finding generics, looking at what your insurance covers, etc.?

Many EHRs have usability problems and many have been implemented poorly. As with all technological innovations in professional settings though, they often create longing for the good old days, which may never had existed. We need to remember that medical records could not continue to exist as paper records written more as reminders than searchable, definitive records.

EHRs have changed provider’s roles. They have to create records not just for themselves, their partners, etc., but also for other providers and analysts they may never meet. As patients, we also need to understand that EHRs, like word processing, cell phones, and the internet itself are far from perfect. Banishing them may allow more personal time for you, but what will it mean for your care, your doctor or for the next patient?

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com.For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manager doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst, a role he recently repeated for a Council member.

It’s no secret that ONC’s meaningful use program’s a mess. I’m not sure there is an easy way out. In some respects, I wish they would go back and start over, but that’s not going to happen. They could do something to see daylight, but it won’t be either easy or simple. As I‘ll outline, ONC could adopt a graduated system that keeps the MU standards, includes terribly needed interoperability and usability standards, but does not drive everyone crazy over compliance.

MU’s Misguided Approach

ONC has spent much time and money on the MU standards, but has painted itself into a corner. No one, vendors, practioners or users is happy. Vendors see ONC pushing them to add features that aren’t needed or wanted. Practioners see MU imposing costs and practices that don’t benefit them or their patients. Users see EHRs as demonic Rube Goldberg creations out to frustrate, confuse and perplex. To boot, ONC keeps expanding its reach to new areas without progress on the basics.

Most the MU criticisms I’ve seen say MU’s standards are too strict or too vague. Compliance is criticized for being too demanding or not relevant. Most suggested cures tinker with the program: Eliminate standards or delay them. I think the problems are both content and structure. What MU needs is a return to basics and a general restructuring.

Roots of the MU Program’s Problems

It’s easy to beat up on ONC’s failures. Almost everyone has a pet, so I’ll keep mine short.

MU1: Missed Opportunities. MU’s problems stem from its first days. ONC saw EHRs as little more than database systems that stored and retrieved encounters. Data sharing only this:

MU2: Punting the Problems. ONC’s approach to interoperability and usability was simple. Interoperability was synonymous with continuity of care and public health reports. Every thing else was put off for future testing criteria.

ONC’s usability approach was equally simple. Vendors defined their usability and measurement. The result? Usability’s become a dead topic.

Interoperability

ONC has many good things to say about the need for interoperability. Its recent Roadmap is thoughtful and carefully crafted. However, the roadmap points out just how poor a job ONC has done to date and it highlights, to me, how much ONC needs to rethink its entire MU approach.

Changing ONC

In one of his seminal works on organizations, C. Northcote Parkinson said it’s almost impossible to change a failing organization. His advice is to walk away and sew salt. If you must persist, then you should adopt the heart of a British Drill Sergeant, that nothing is acceptable. Alas, only Congress can do the former and I’m way too old for military service, so I will venture on knowing it’s probably foolhardy, but here goes.

New Basic Requirements

A better approach to MU’s core and menu system would allow vendors to pick and choose the features they want to support, but require that all EHRs meet four basic standards:

Data Set. This first standard would spell out in a basic, medical data set. This would include, for example, vitals, demographics, meds, chief complaints, allergies, surgeries, etc.

Patient ID. A patient’s demographics would include a unique patient identifier. ONC can use its new freedom in this area by asking NIST to develop a protocol with stakeholders.

Interoperability. EHRs would have to transmit and receive, on demand, the basic data set using a standard protocol, for example, HL7.

Usability. Vendors would have to publish the results of running their EHR against NIST’s usability standard. This would give users, for the first time, an independent way to compare EHRs’ usability.

All current EHRs would have to meet these criteria within one year. Compliance would mean certification, but EHRs that only met these criteria would not be eligible for any funding.

Cafeteria Program. For funding, vendors would have to show their EHR supported selected MU2 and MU3 features. The more features certified, the more eligible they’d be for funding.

Here is how it would work. Each MU criteria would have a one to ten score. To be eligible for funding, a product would have to score 50 or more. The higher their score, the higher their funding eligibility.

Provider Compliance. Providers would have a similar system. ONC would assign scores of one to ten for each utilization standard. As with vendors, implementing organizations would receive points for each higher utilization level. That is, unlike current practice, which is all or nothing, the more the system is used to promote MU’s goals the higher the payments. This would permit users to decide which compliance criteria they wanted to support and which they did not.

Flexibility’s Advantages

This system’s flexibility has several advantages. It ends the rigid nature of compliance. It allows ONC to add new criteria as it sees fit giving it freedom to add criteria as needed or to push the field.

It achieves a major advancement for users. It not only tells users how products perform, but it also lets them choose those that best fit their needs.

Vendors, too, benefit from this approach. They would not only know where they stood vs. the competition, but would also be free to innovate without having to include features they don’t want.

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com.For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manager doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst, a role he recently repeated for a Council member.

The other day, I had lunch at DC’s Soupergirl with the redoubtable Chuck Webster, workflow tool maven and evangelist. We talked a lot and discovered that both of us had a warm spot for the classic neighborhoods near Atlanta’s Piedmont Park. He as a transplant and I as a native.

More to this blog’s point, we discussed the state of EHRs and their numerous problems. Chuck wondered if EHR, per se, had become a bad brand? It’s a good question. Have we seen a once promising technology become, as has managed care, a discredited healthcare systems? It’s an easy case to make for a host of reasons, such as these:

Poor Usability. There are scads of EHRs in the marketplace, but few, if any, have a reputation as being user friendly. Whenever I first talk to an EHR user, I wait a few minutes while they vent about:

How they can’t put in or get out what they need to,

Their PCs being poorly located, inflexible or the wrong footprint,

Data that’s either missing, cut off or hard to find,

Logging in repeatedly,

Transcribing results from one system to put it in another,

Wading through piles of boilerplate, to get what they need etc., etc.

Having to cover PCs with sticky note workarounds.

As for patients, my friend Joe, a retired astrophysicist, is typical. He says when his doctor is on her EHR she doesn’t face him. She spends so much time keying, he feels like he’s talking to himself.

Now, it’s not completely fair to blame an EHR for how it’s implemented. The local systems folks get a lot of that blame. However, vendors really have failed to emphasize best practices for placing and using their systems.

Missing Workflows. EHRs, basically, are database systems with a dedicated front end for capturing and retrieving encounters and a back end for reporting. To carry out, their clinical role they have to be flexible enough to adapt to varying circumstances with a minimum of intervention.

For example, when you make an appointment for a colonoscopy, the system should schedule you and the doctor. It should then follow rules that automatically schedule the exam room, equipment, assign an anesthetist, and other necessary personnel, etc.

When you come in, it should bring up your history, give your doctor the right screens for your procedure, and have the correct post op material waiting. General business software workflow engines have done this sort of thing for years, but such functions elude many an EHR. EHRs without needed workflow abilities increase staff times and labor costs. They also mean users miss important opportunities and potential errors increase.

Data Sharing. Moving from paper to electronic records promised to end patient information isolation. Paper and faxed records can only be searched manually. However, with a structured electronic record, redundant entry would be reduced and information retrieval enhanced. Or so the argument went, but it hasn’t worked out that way.

While there are systems, such as the VA, Kaiser and various HIEs that fulfill much of the promise, it is still a potential rather than a reality for most of us. There are two basic reasons for this state of affairs: ONC’s mishandling of interchange requirements and one member of Congress’ misplaced suspicions.

ONC’s Role. ONC’s Meaningful Use program is meant to set basic EHR standards and promote data interchangeability.

When it comes to these goals, MU fell down from the start. MU1 could have been concise requiring an EHR to capture a patient’s demographics, vitals, chief complaint and meds.

Most importantly, MU could have made this information sharable by adopting one of HL7’s data exchange protocols. This would have given us a basic, national EHR system. Instead, MU focused on too many nice to have features, leaving data exchange way down the list.

ONC has tried to correct its data interchange a failing in MU2 to a degree, but it’s not there yet. Here’s what GAO, has to say about ONC’s efforts:

HHS, including CMS and ONC, developed and issued a strategy document in August 2013 that describes how it expects to advance electronic health information exchange. The strategy identifies principles intended to guide future actions to address the key challenges that providers and stakeholders have identified. However, the HHS strategy does not specify any such actions, how any actions should be prioritized, what milestones the actions need to achieve, or when these milestones need to be accomplished. GAO Report-14-242, March 24, 2014. Emphasis added.

Ron Paul. The other important obstacle to interchange came from Congress. When Congress passed HIPAA in 1996, it mandated that HHS develop a national, patient ID. However, in 1998 Ron Paul, (R-TX) deduced that since HHS wanted the ID system, it therefore wanted to put everyone’s medical records in a government database. He saw this as a threat to privacy. He got a rider added to HHS’s budget forbidding it to implement the ID system or even discuss one.

The ban’s remained in succeeding budgets. The rider has created a national medical data firewall for each of us, which hinders all of us. Paul’s gone from Congress, but Congress continues the ban. As Forbes’ Dan Munroe wrote about Paul’s ban:

The health data chaos we have today doesn’t allow for interoperability, portability or mobility. It’s why fax machines remain the ‘lingua franca” of U.S. healthcare. Every healthcare entity in the U.S. sees each patient, event and location as unique to them. For lack of a single identifier, there’s no easy or cost-effective way to coordinate patient care. Emphasis added.

While the lack of a patient ID is not EHRs fault, it noticeably reduces their ability to interchange information. State or other HIE’s are, in effect, workarounds for lack of a uniform ID. This situation adds to the perception of EHRs as unresponsive technology.

Onerous Agreements. As many an EHR buyer has found, vendors see EHRs as a sellers’ market. They use this to write onerous license agreements exempting their products from adhering to standards such as MU or from responsibility for costly errors or omissions.

These agreements not only limit liability, but often silence a buyer’s adverse comments. The effect is to cut buyers from any meaningful recourse. This shortsighted practice adds one more layer to the EHR industry’s image as unresponsive, self serving and defensive.

Whither the Brand?

The question then is are things so bad that EHR needs rebranding? If so, how should this be done by calling EHRs something else, advocating for a different technology, or yet another alternative?

For some brands, a new name along with some smart PR will do. That’s how Coca Cola reversed its New Coke fiasco. EHRs have a tougher problem. EHRs are not a one vendor product. They are a program class. Reforming EHR’s brand will take more than effective PR. It will take pervasive technical and policy changes.

Change From Where?

Change in a major technical field, as in public policy, requires either overcoming or going around inertia, habit, and complacency. EHRs are no exception. Here are some ways change could happen.

External Events. The most likely source of change is a crisis that brings public pressure on both the industry and government. There is noting like a tragedy to grab public attention and move decision makers off the dime. I don’t want it to occur this way, but nothing like a tragedy makes events go into fast forward and move issues from obscure to inevitable. Given EHRs many patient safety problems, this is all too likely an outcome.

ONC Initiative. ONC could step in and help right matters. For example, as I have advocated, ONC could run NIST’s usability protocols for all systems seeking MU certification. It could then publish the test results giving users a needed, common benchmark. This, in turn, could be a major push to get vendors to regard usability, etc., as an important feature.

ONC is not inclined to do this. Instead, it asks vendors to pick one of several versions of user centric technology. As Bennett Lauber, Chief Experience officer of The Usability People recently told HIEWatch:

“Usability certification for meaningful use really isn’t a test the way the rest of the certification process is. (Testers) go out and observe users, and report back to the certifiers,” Lauber reports. “There seem to be different sets of evaluation criteria because ONC has not really defined usability yet….” Emphasis Added.

Recently appointed ONC Coordinator, Dr. Karen Desalvo, unlike her predecessors, has been frank about changing ONC’s course. She’s revamped her advisory committee structure and spoken about going beyond meaningful use to big data.Notably, she understands the need for and the problems of interoperability. However, she’s not offered any changes in standards. ONC is in the best position to implement real standards, but for both political reasons; it’s unlikely to do so.

To chill things politically, vendors only have to find a few Congressmen who’ll, for a well placed contribution, will send ONC vendor drafted letters threatening its appropriation, committee reviews, etc. It can happen otherwise, but as Damon Runyon has said, “The race is not always to the swift, nor the battle to the strong, but that’s the way to bet.”

User Revolt. The most notable user push back to the status quo has involved unilateral EHR vendor agreements.

As Katie Bo Williams of Healthcare Drive (edited by Hospital EMR and EHR’s Anne Zieger) has notably described, major lawsuits are costing some vendors dearly. The industry, however, has yet to set buyer agreement standards that could aid its and EHRs’ reputation.

These lawsuits might chastise vendors, but users will need to become bolder if they want change. EHR vendors have an association to protect their interests. So do hospitals, physicians, practice managers, etc. Users are the one group that’s not represented.

You may belong to this or that product’s user group, but there is no one group that looks after EHR user’s interest. If there were a well organized and led EHR user group that lobbied for better usability, workflow tools and universal data exchange etc., then these issues would become more visible. More importantly, users would be able to demand a place at the table when ONC, etc., makes policy.

Those interested in patient safety, too, are taking some new directions. Recently, ECRI convened the Partnership for Promoting Health IT Patient Safety to promote changes, within “a non punitive environment,” that is, in a collaborative setting among vendors, practioners, safety organizations, etc. While the group has not issued any reports, it offers two hopeful signs.

The group’s advisory panel includes experts, such as, MIT’s Dr. Nancy Leveson, who works in aeronautic and ballistic missile safety systems. The other factor is that the group has consciously sought to give vendors a place where they see the impact their products have on patient safety without the threat of litigation. Whether the group can bring this off and influence the market remains to be seen.

Technical Fix. It’s possible users may decide to fix EHR’s problems themselves. For example, the University of Pittsburgh Medical Center (UPMC) uses a combination of EPIC, Cerner and its own clinical systems. It wanted to pull patient information into one, comprehensive, easily used profile. To do this, the Center developed a new, tablet front end that overcomes a variety of common EHR problems.

Once a major actor, such as Pitt, shows there is a market, others will explore it. You’ll know it’s a real trend, when a major vendor buys a front end start up and brands it as its own.

Natural Turnover. Finally, John recently raised the question of EHRs’ future in What Software Will Replace EHR? He thinks that change will come organically as more technically robust software pushes out the old.

Slowly replacing current EHRs with new tools is the most likely path. However, a slow path may be the worst outcome. Slow turnover would give us a mixture of even more incompatible systems. This would make the XP installed base problem look simple.

The EHR brand reminds me of a politician with both high positives and negatives. It may be liked by many, however, it also has a lot of baggage. As with a candidate in that position, something will have to change those negatives or it will find itself just an also ran.